From the Guidelines
Oral terbinafine 250mg daily for 6 weeks (fingernails) or 12 weeks (toenails) is the most effective treatment for onychomycosis, with higher efficacy rates compared to itraconazole, as demonstrated in a multicentre, randomized trial involving 508 subjects 1. The management of onychomycosis involves a combination of oral and topical antifungal medications, along with proper nail care.
Treatment Options
- Oral terbinafine is the first-line treatment, with a dose of 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection, due to its higher efficacy and tolerability compared to itraconazole 1.
- Itraconazole is an alternative, with a dose of 200 mg per day for 12 weeks continuously, or alternatively as pulse therapy at a dose of 400 mg per day for 1 week per month, with two pulses recommended for fingernail onychomycosis and three pulses for toenail onychomycosis 1.
- Topical options like ciclopirox 8% nail lacquer or amorolfine 5% nail lacquer can be used for mild cases or as adjunctive therapy, applied daily after filing the nail surface 1.
Important Considerations
- Treatment success requires patience, as complete nail regrowth takes 6-12 months for fingernails and 12-18 months for toenails.
- Fungal infections thrive in warm, moist environments and penetrate the nail plate, making them difficult to eradicate without consistent, long-term treatment.
- Recurrence is common (10-50%), so preventive measures should continue even after apparent cure.
- During treatment, it is essential to keep nails short, dry, and clean, wear breathable footwear, and avoid sharing nail tools.
- For severe cases, surgical or chemical nail removal may be necessary before starting medication.
Monitoring and Safety
- Baseline liver function tests and a complete full blood count are recommended in adult patients with a history of hepatotoxicity or haematological abnormalities before starting terbinafine or itraconazole treatment 1.
- Monitoring hepatic function tests is recommended in patients with pre-existing deranged results, in those receiving continuous therapy for more than a month, and with concomitant use of hepatotoxic drugs 1.
From the FDA Drug Label
INDICATIONS AND USAGE ... Ciclopirox Topical Solution, 8%, (Nail Lacquer), as a component of a comprehensive management program, is indicated as topical treatment in immunocompetent patients with mild to moderate onychomycosis of fingernails and toenails without lunula involvement, due to Trichophyton rubrum The comprehensive management program includes removal of the unattached, infected nails as frequently as monthly, by a health care professional who has special competence in the diagnosis and treatment of nail disorders, including minor nail procedures. DOSAGE AND ADMINISTRATION Ciclopirox Topical Solution, 8%, (Nail Lacquer), should be used as a component of a comprehensive management program for onychomycosis. Removal of the unattached, infected nail, as frequently as monthly, by a health care professional, weekly trimming by the patient, and daily application of the medication are all integral parts of this therapy
The management options for Onychomycosis (fungal nail infection) include:
- Topical treatment: Ciclopirox Topical Solution, 8%, (Nail Lacquer) as part of a comprehensive management program
- Removal of infected nail: by a health care professional as frequently as monthly
- Nail care: weekly trimming by the patient and daily application of the medication
- Comprehensive management program: including removal of unattached infected nails, trimming of onycholytic nail, and filing of excess horny material by professionals trained in treatment of nail disorders 2, 2
From the Research
Management Options for Onychomycosis
The management options for onychomycosis, a chronic fungal infection of the nail, include various modalities such as surgical, chemical, topical, and oral methods 3. The choice of treatment depends on the severity and extent of the infection, as well as the type of causative agent.
Oral Treatment Options
Oral antifungal agents such as terbinafine, itraconazole, and fluconazole are effective in treating onychomycosis, with terbinafine producing the best results for dermatophyte infections 4, 5. For non-dermatophyte infections, such as those caused by Candida or molds, itraconazole or fluconazole may be recommended 4, 6.
Topical Treatment Options
Topical antifungal agents such as amorolfine and ciclopirox can be used to treat onychomycosis, especially for mild to moderate infections 7, 6. These agents can be used alone or in combination with oral antifungal agents to enhance treatment efficacy.
Combination Therapy
Combining oral and topical antifungal agents may be beneficial in treating onychomycosis, particularly for non-dermatophyte infections 7. The combination of terbinafine and amorolfine has been shown to have additive or synergistic effects against certain fungal pathogens.
Treatment Guidelines
Treatment guidelines for onychomycosis recommend the use of oral antifungal agents such as terbinafine for dermatophyte infections, and itraconazole or fluconazole for non-dermatophyte infections 4, 6. Topical antifungal agents can be used for mild to moderate infections, or in combination with oral agents for more severe infections. The choice of treatment should be based on the severity and extent of the infection, as well as the type of causative agent.
- Key points to consider when selecting a treatment option: